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Thanks to those who participated in a great discussion in AMR last week. I wanted to share some of what we talked about here…

Sexual assault is an unusal complaint inside of a primary care clinic. Many victims head straight for the ER or a Rape Crisis Center, others never report their attack. But for many, their primary care doctor may seem like a trusted source for health care in a very scary and chaotic situation. Since it is also a scary and chaotic situation for the provider, I thought that an organized process may help you know what to do in such a scenario.

Legal Issues

The patient may need or want an exam in order to collect evidence for future charges against an attacker. There is a very specialized process that is used to collect evidence, and maintain the chain of custody. I would recommend that you contact your Emergency Dept or Rape Crisis Center for help. In Birmingham, the Crisis Center offers Sexual Assault Nurse Examiner (SANE) Exams in a safe and secure facility, and may be a more comfortable alternative to an ED. They have a SANE nurse on call 24/7. Many times, this exam must be done within 72 hours of the attack.

Pregnancy Prevention

Most women should be offered post-coital contraception after a sexual assault. The most effective oral option is Le
vonorgestrel, (Plan B is one brand name). Ulipristal (Ella) is a newer form of emergency contraception that is effective up to 120 hours after unprotected sex.

STI Prevention

The CDC recommends antibiotic prophylaxis for GC, Chlamydia, and Trichomonas. If your patient declines, you should see her back in a week for testing. You need to give (all single dose therapies):

Ceftriaxone 250mg IM for Gonorrhea

Azithromycin 1g PO for Chlamydia

Metronidazole 2g PO for Trichomonas

Hepatitis B Prevention

If the Hepatitis B status of the attacker is not known, and the victim is not already immune, the victim should receive the Hepatitis B vaccine on first visit, and then at 1 and 6 months. If the attacker has Hepatitis B, then you should offer HBIG.

HIV Prevention

There is some data that post-exposure prophylaxis with antiretroviral drugs prevents HIV transmission. Most of this data is in the healthcare setting, when folks like us are exposed with needles. The studies done in sexual exposure and IV drug users are all small and observational. Side effects with these medicines are fairly common, and usually of the GI variety.

Given limited data, and relatively low risk of transmission for a single sexual exposure (0.1% for consensual vaginal intercourse and 2% for consensual anal intercourse- transmission rates with nonconsensual sex are likely to be higher), the CDC only recommends post exposure prophylaxis (PEP) if:

WITH: semen, vaginal fluid, blood, rectal secretions, milk, or other bodily fluids that are known to transmit HIV.

However, they do give you an option to treat other patients on a case-by-case basis. Many experts recommend that PEP is offered to all victims of sexual assault that present in the first 72 hours and have a chance at HIV exposure. If you were going to prescribe, it should start within 72 hours (the earlier the better), and continue for 4 weeks. Three drug combinations are usually used, the same as in occupational HIV PEP.

Tenofovir/emtricitabine 300/200 plus Dolutegravir 50mg once daily

Tenofovir/emtricitabine 300/200 plus Raltegravir 400mg twice daily

Psychologic Support

Probably the most important thing that you can do. Your patient came to use because you were trusted, available, and supportive. You need to continue to be those things. After an assault, many victims will struggle with nightmares, anorexia, guilt, anxiety, and PTSD. As a primary care doctor, you can gently ask about these issues, and guide your patients to helpful therapies and supportive environments. Again, rely on your local resources for crisis counseling and psychiatry, in addition to using all of your own talents.

Here is a NEJM article (subscription needed) if you are interested in reading more: NEngl J Med 2011; 365:834-841.

Thanks to all who participated and attended the Grey Zone: Acute Back Pain lecture last Tuesday. I learned a lot, hope that you did as well. As is often the case with grey zone lectures, we spend so much time talking with the panel that we miss some of the didactics at the end. Here are some highlights that I wanted to be sure to cover.

99% of patients will acute back pain will get better, often without you doing much at all. Gentle activity, NSAIDs, and time will take care of most. If it goes on for two-week or so, add some formal PT. The activity is good, but PT will also use massage, heat, TENS and US to help get the muscles to relax.

Red flags aren’t all they are made out to be, but are definitely a clue to slow down your thinking about a patient with back pain. You may not need to do more just because a patient has one red flag- 80% of patients will have at least one.

Yellow Lights mean “slow down and prepare to stop” according to my 5-year-old, and that is just what these should signs and symptoms should make you do.

Age >70

History of cancer, not active malignancy

IV drug use

Osteoporosis, use of steroids

Immunosuppression

On the other hand, the red lights should make you stop and seriously consider more imaging, consultation, or other workup. You may still be justified in delaying imaging if there are one of these present, but you need to be extra sure that it is the right thing to do.

Known metastatic cancer

Trauma

Recent spinal surgery

Bowel/Bladder incontinence

Fever (without another reason)

Weight loss (without another reason)

Saddle anesthesia, decreased rectal tone

Progressive motor or sensory loss

If you do need to do more workup, let your differential diagnosis be your guide as to what needs to happen. Here are some suggestions:

Vertebral Fracture: either from osteoporosis or trauma. Plain films are quite helpful, CT is important for traumatic fractures- will give a better idea of the extent of the fracture and the mechanism.

Metastatic disease: Plain films are a place to start. MRI would be quick to follow if there are neurologic findings. Bone scan may be useful in a high risk patient with a less clear picture.

Cauda Equina Syndrome: Think this if there is saddle anesthesia, bowel/bladder incontinence. MRI if you are concerned, with quick referral to NSGY.

Spinal Stenosis: Pseudoclaudication is the classic sx here: predictable pain with standing or walking, better with rest. Vascular claudication gets better quickly with rest, pseudoclaudication takes 20-30 minutes or more. Plain films may show misalignment, but the MRI is going to clinch the diagnosis.

Epidural abcess: Unexplained fever and weight loss in a high risk patient: IV drugs, recent spinal surgery, recently septic, decubital ulcers all are all risks. MRI is the imaging test.

Here’s a great patient centered video about low back pain to bring these points home to your patients.

Like this:

This post is inspired by a clinic conversation yesterday. Our clinical question was about which antidepressant to choose. It can kind of feel like a game at times: you make a random pick,and see what happens. Is there a more evidence based way to go about it?

The evidence behind SSRIs is a whole different post, but suffice it to say that they have similar efficacy and tolerablity. Citalopram (Celexa), Paroxetine (Paxil), Fluvoxamine (Fluvox), Fluoxetine (Prozac), Sertraline (Zoloft), and Escitalopram (Lexapro) are all available widely.

So how to decide what to prescribe when a patient is sitting in front of you. You could pick based on your favorite commercial, or which drug rep bought the best dinner, but maybe there is a less biased method.

Generally we use patient preference, side effects, and cost as the driving factor in picking among similar medicines. So I thought I’d review the last two for you here.

Cost is easier. All of these come in generic forms now. Citalopram and paroxetine are on the $4 drug list at WalMart. A quick search on GoodRx shows prices around $5 for fluoxetine, $8-10 for sertraline, and $15 for fluvoxamine and escitalopram.

Artwork by Robin D Snyder. Text at the bottom of the screen says: “Certain Side Effects May Occur”.

Now for side effects. All of them can cause weight gain, decreased libido, and diarrhea, which are often pretty important to patients. Scarier side effects are QTc prolongation, and hypotension and anticholinergic effects, which may make you think twice about prescribing to an older patient. You can sort out which side effect is most important to your patient, and then steer clear of the worst offenders.

Weight gain: Paroxetine seems to be the worst, anecdotally I have had complaints about citalopram as well.

Sexual Dysfunction: A big problem with all of them. Again, paroxetine is the worst, but none are really great. Your best bet if this is a big factor for your patient: use bupropion instead of an SSRI.

GI side effects: Diarrhea is the most common complaint from a GI standpoint. Sertraline is the worst offender here.

QTc prolongation: Citalopram, Escitalopram, and Fluoxetine are the ones known to cause some QT troubles. The others are probably OK.

Hypotension and anticholinergic effects: Again, paroxetine is the troublemaker here, although any can contribute.

Often listed as a side effect is agitation or “activation”. Sometimes I try to use this as a benefit. If patients are particularly apathetic, or have the psychomotor retardation often seen in major depression, you can use this to your advantage. I think of fluoxetine and sertraline as being more “activating“, while citalopram and paroxetine are more sedating. The latter two can be helpful for the anxious patient.

At the end of the day, I don’t know that there is a ton of difference between these. I rely on patient experience and preference to guide my choice more than anything else.